Release Date : July 10 2024
Diabetes Mellitus: ADA Standards of Medical Care in Diabetes (2024)
About the Guideline
- The American Diabetes Association (ADA) has developed diabetes care standards for more than 30 years.
- The standards are evidence-based and undergo a formal peer review process by the ADA Professional Practice Committee and Board of Directors.
- ADA standards are published in Diabetes Care every January.
- These care standards were updated in December 2023.
Key Clinical Considerations
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Become familiar with the recommendations and best-practice statements provided in this guideline, especially if you work in an acute care setting.
The guideline and protocols aim to integrate components of care, address the complexity of diabetes management, standardize order entry, individualize care, enhance patient safety, and allow patient self-management when appropriate.
Improving Care and Promoting Health
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- Assess and consider the patient's social context (e.g., decision-making and self-management support), including food insecurity, housing instability, current health status (including comorbidities, age, race, language barriers), and financial barriers (including the cost of treatment and medications) when making treatment decisions.
- Include local community resources as referrals.
- Telemedicine increases access to care for patients with diabetes.
- The prevention and management of diabetes should be incorporated into patient care and treatment.
Diagnosis and Classification
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- Diabetes mellitus type 1
- Type 1 diabetes is caused by autoimmune beta-cell destruction that usually leads to absolute insulin deficiency.
- Diagnosis is based on classic three Ps (polyuria, polyphagia, polydipsia) plus two of the following lab results gathered either from the same blood sample or from two different samples:
- A1c level of 6.5% or higher
- Fasting plasma glucose (FPG) greater than 126 mg/dL
- 2-hour plasma glucose (PG) greater than 200 mg/dL during an oral glucose tolerance test (OGTT)
- Random blood glucose level greater than 200 mg/dL
- Standardized islet autoantibody tests are recommended for individuals with certain risk factors.
- Diabetes mellitus type 2
- Type 2 diabetes is a result of the progressive loss of beta-cell insulin secretion, often with the concurrent development of insulin resistance and metabolic syndrome.
- Diagnosis is indicated by two of the following lab results gathered either from the same blood sample or from two different samples:
- A1c level of 6.5% or higher
- FPG greater than 126 mg/dL
- 2-hour PG greater than 200 mg/dL during an OGTT
- Random blood glucose level greater than 200 mg/dL
- Gestational diabetes mellitus (GDM) is diagnosed in the second or third trimester when overt diabetes was not present prior to pregnancy.
- Prediabetes
- Characterized by glucose levels that do not fall in the diabetic range but that are too high to be considered normal. Prediabetes is diagnosed by the presence of the following:
- A1c level of 5.7% to 6.4%, or
- FPG of 100 mg/dL to 125 mg/dL, or
- 2-hour PG during 75 g OGTT of 140 mg/dL to 199 mg/dL.
- Testing should be performed in asymptomatic individuals who are overweight or obese (body mass index [BMI] greater than or equal to 25 kg/m2, or greater than or equal to 23 kg/m2 for Asian Americans) with any of the following risk factors:
- Race at high risk for developing diabetes (African American, Native American, Latino, Pacific Islander, Asian American)
- First-degree relative with diabetes
- History of cardiovascular disease (CVD)
- Hypertension (blood pressure greater than or equal to 130/80 mmHg, or currently receiving hypertensive therapy)
- High-density lipoprotein (HDL) cholesterol less than 35 mg/dL and/or triglycerides greater than 250 mg/dL
- Individuals with polycystic ovarian syndrome (PCOS)
- Physically inactive people
- Adults over the age of 35
- Individuals with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) should be screened with a fasting glucose test before beginning antiretroviral therapy or before changing therapies.
- History of pancreatitis
- Exposure to high-risk medications, such as glucocorticoids, statins, thiazide diuretics, and second-generation antipsychotic medications
- Individuals prescribed antipsychotic medications should be screened at baseline, with repeat screening 12 to 16 weeks after initiation of therapy, if clinically indicated, then annually.
- Women who have been diagnosed with GDM should be tested every three years for life.
- Individuals with prediabetes should be tested annually.
- Specific types of diabetes
- Monogenic diabetes syndromes (neonatal diabetes and maturity-onset diabetes of the young [MODY])
- Diseases of exocrine pancreas (cystic fibrosis-related diabetes and pancreatitis)
- Drug-induced or chemically induced diabetes related to glucocorticoid use, treatment for HIV/AIDS, or posttransplant-related treatment
Prevention or Delay of Diabetes Mellitus Type 2
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- Test annually for the development of type 2 diabetes in individuals previously diagnosed with prediabetes.
- Individuals with prediabetes should be referred to a lifestyle modification program. Encourage an increase in moderate-intensity physical activity (brisk walking) for at least 150 minutes per week, with a weight-loss goal of 7% of initial body weight.
- Consider more intensive prevention approaches for individuals at high risk of progression to diabetes.
- Consider technology-assisted diabetes prevention programs, including smartphone and web-based applications and telehealth programs, to increase adherence.
- Medical nutrition therapy should be included in any lifestyle modification plan. Encourage the intake of quality foods such as nuts, legumes, whole grains, fruits, and vegetables, and limit the intake of refined and processed foods.
- Consider metFORMIN for the prevention of type 2 diabetes in individuals with prediabetes, especially in women with a history of GDM, a BMI greater than or equal to 35 kg/m2, or those over 60 years old.
- Vitamin B12 deficiency is associated with long-term use of metFORMIN, and B12 levels should be measured periodically.
- Prediabetes is associated with heightened cardiovascular risk. Screen and treat modifiable risk factors.
- Discourage the use of tobacco. Tobacco use increases the risk for type 2 diabetes.
Comprehensive Medical Evaluation and Assessment of Comorbidities
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- Patient-centered collaborative care should focus on communication and should assess literacy, numeracy, health literacy, and any potential barriers to care.
- Care should be managed by a multidisciplinary team that may include primary care practitioners, specialists, dietitians, pharmacists, podiatrists, and any other health care practitioner that is appropriate.
- A comprehensive medical evaluation should be performed, and follow-up and ongoing care should be established.
- Provide vaccinations to adults and children with diabetes routinely as recommended, such as vaccines for influenza, pneumococcal pneumonia, hepatitis B, and COVID-19.
- The following should be performed for individuals with diabetes and comorbid conditions:
- Assessment of CVD risk.
- Screening for autoimmune thyroid disease and celiac disease.
- Screening for bone health and assessment of fracture risk, as appropriate.
- Assessment for cognitive impairment and dementia. In patients with dementia or cognitive impairment, intensive glucose control cannot be expected, and treatment should be focused on avoiding significant hypoglycemia.
- Individuals with prediabetes or type 2 diabetes and elevated liver enzymes or a fatty liver noted by ultrasound should be evaluated for nonalcoholic steatohepatitis and liver fibrosis.
- For patients with medically refractory chronic pancreatitis who require a total pancreatectomy, consider islet autotransplantation to prevent postsurgical diabetes.
- Patients with HIV should be screened for prediabetes and diabetes at the following intervals:
- Prior to initiation of antiretroviral therapy (ART), and 3 to 6 months after initiation.
- When switching ART, and 3 to 6 months after switching.
- If initial screening is normal, rescreen with a fasting blood glucose yearly.
- A morning testosterone level should be measured for men with diabetes experiencing symptoms of hypogonadism, such as decreased libido or erectile dysfunction.
- Mental health screenings should be performed for all patients with diabetes and for those with diabetes who are currently receiving antipsychotic medication. Assessments should include screening for anxiety, depression, disordered eating, and eating disorders.
Lifestyle Management
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- Evaluate the need for education about diabetes self-management at each visit, if complications arise, and at any transitions of care.
- Diabetes self-management education should be patient-centered and take place in an individual or group setting; it should include the use of appropriate technology.
- Psychosocial screening and assessment should include evaluation for signs of anxiety, depression, diabetes distress, cognitive changes, and disrupted or disordered eating.
- Medical nutrition therapy and education is recommended and should address the following:
- Consistent carbohydrate intake (individualized to each patient and added to other diet orders).
- Consumption of nutrient-dense carbohydrates that are high in fiber and not highly processed.
- Emphasis on fruits, nonstarchy vegetables, dairy, whole grains, and minimal sugar.
- Replacement of fruit juices and other sugar-sweetened drinks with water.
- Effectiveness of nutrition therapy.
- Energy balance (weight management).
- Eating patterns and macronutrients (carbohydrates, protein, and fats).
- Individuals with type 2 diabetes should avoid sources of carbohydrates high in protein.
- Micronutrients and herbal supplements are not generally recommended because there is no clear evidence of efficacy.
- Alcohol may be consumed in moderation (one drink per day for adult women, and two drinks per day for adult men).
- Sodium should be limited to less than 2,300 mg/day.
- Nonnutritive sweeteners are recommended in moderation.
- A Mediterranean-style diet may be considered.
- Address intermittent fasting and time-restricted eating.
- Screen for food insecurity.
- Physical activity recommendations, per practitioner, include the following:
- Children and adolescents should engage in at least 60 minutes per day of moderate-intensity activity.
- Adults with type 1 and type 2 diabetes should engage in at least 150 minutes per week of moderate-intensity activity and in 2 to 3 sessions per week of resistance exercise. Those with type 2 diabetes should reduce sedentary behavior. Sitting for longer than 30 minutes should be interrupted.
- Older adults should engage in flexibility and balance training 2 to 3 times per week.
- Tai Chi, gardening, dancing, swimming, walking, housework, and yoga can be added per the preferences for older adults.
- Encourage the cessation of all tobacco and e-cigarette products.
- Perform sleep health screening due to the complex association between sleep and diabetes.
Glycemic Targets
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- For patients who are meeting their treatment goals, perform an A1c test at least twice per year.
- For patients whose therapy has changed or for those not meeting their glycemic goals, perform an A1c test at least four times per year.
- Treatment changes can be made more efficiently with the use of point-of-care (POC) A1c testing.
- A reasonable glycemic goal for nonpregnant adults is an A1c less than 7% (in the absence of significant hypoglycemia).
- Tighter control (A1c less than 6.5%) may be reasonable for select patients.
- A less stringent goal of A1c less than 8% may be appropriate for individuals in the following situations:
- History of severe hypoglycemia
- Advanced microvascular and/or macrovascular complications
- Extensive comorbidities
- Difficult to control, long-standing diabetes
- Limited life expectancy
- Glycemic targets and goals should be reassessed periodically.
- For individuals at risk for hypoglycemia, asymptomatic and symptomatic hypoglycemia should be discussed at each visit.
- For hypoglycemia in conscious patients, glucose (15 to 20 g) is the preferred treatment for a blood glucose level less than 70 mg/dL (Level 1); however, any carbohydrate with glucose may be used.
- Repeat blood glucose measurement 15 minutes after treatment. If the patient is still hypoglycemic, repeat the treatment.
- To prevent recurrence, a meal or snack should be consumed once blood glucose has returned to normal levels.
- For patients who experience hypoglycemia with a blood glucose less than 54 mg/dL and who are either asymptomatic or with mild neuroglycopenic symptoms (Level 2), or with severe symptoms that require assistance of another person (Level 3), treat with oral glucose, if appropriate. In addition, glucagon should be prescribed for these patients. Education should be provided to school and work personnel, caregivers, and family members regarding the administration of glucagon.
- Reevaluate the patient's treatment regimen and cognitive function if persistent hypoglycemia occurs.
Diabetes Technology
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- Diabetes technology is the term used to describe any device, hardware, or software that is used to manage blood glucose levels, prevent complications, decrease the burden of living with diabetes, and improve a patient's quality of life.
- Use insulin syringes or insulin pens for insulin delivery.
- Consider patient preference, insulin type, dosing regimen, cost, and self-management capabilities. Use insulin injection aids for patients with impaired dexterity or impaired vision.
- Insulin pumps are an option for most adults and youth with type 1 diabetes, and they may also be considered for patients with type 2 diabetes requiring multiple daily insulin injections.
- Individuals using an insulin pump or administering multiple daily insulin injections should monitor blood glucose either by using continuous glucose monitoring or by self-monitoring at the following times:
- Fasting
- Prior to meals and snacks
- At bedtime
- Periodically prior to exercise, and postprandially
- When low blood sugar is suspected
- Prior to driving
- Self-monitoring and continuous glucose monitoring require extensive diabetes education, training, and support for optimal implementation and ongoing use.
- Practitioners should be aware of anything that may interfere with glucose meter accuracy, such as counterfeit or expired strips, abnormal oxygen saturation or temperature, and interfering substances such as high doses of vitamin C, xylose, uric acid, galactose, acetaminophen, and icodextrin.
- Health care professionals should obtain or have basic knowledge in the use and application of diabetes technology.
- Real-time continuous glucose monitoring (CGM) is an additional tool to help improve glucose control and reduce the risk of hypoglycemia.
- CGM should be offered to any individual with type 1 diabetes at the time of diagnosis, and for those with type 2 diabetes who are on multiple daily insulin injections or treated with a continuous subcutaneous insulin infusion.
- Real-time CGM is also a useful tool to lower A1c in adults with type 1 diabetes who are not meeting their glycemic targets.
- It may be useful for patients at risk for frequent hypoglycemic episodes.
- It may help to improve neonatal outcomes and A1c levels in pregnant women with type 1 diabetes.
- For adults requiring frequent glucose testing, intermittently scanned CGM may be considered as a substitute for self-monitoring of blood glucose.
- Allergies, or skin reactions should be assessed.
- Use of an automated insulin delivery system (combined insulin pump and sensor systems), known as a “closed loop” system, may
- Improve glycemic control.
- Reduce nocturnal hypoglycemia.
- Reduce A1c levels and improve time in range.
Obesity Management for the Prevention and Treatment of Type 2 Diabetes
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- Calculate and record BMI at each patient encounter.
- Obesity-related anthropometric measurements should be monitored at least annually.
- For patients with type 2 diabetes who are overweight or obese and ready to lose weight, diet, physical activity, and behavioral therapy to achieve and maintain equal to or greater than 5% weight loss is recommended. Counseling should be done for at least 16 sessions in a 6-months period.
- A 500 to 750 kcal/day energy deficit is recommended to achieve weight loss.
- Diets should be individualized based on medical status, motivation, and life circumstances.
- Once short-term weight-loss goals are achieved, long-term goals should be made, and a long-term maintenance plan should be developed based on the individual needs of the patient (i.e., nutritional needs and preferences).
- For select patients, a diet of 800 to 1,000 kcal/day with total meal replacements may be prescribed for a short time.
- Medications for glucose-lowering or medications for comorbid conditions that are associated with weight gain should be avoided, if possible. Patients with comorbid heart failure should be more frequently assessed and monitored.
- Weight-loss medications may be considered for select patients after the benefits and risks have been discussed.
- A comprehensive readiness and mental health assessment should be performed prior to consideration of metabolic surgery.
- For surgical candidates with type 2 diabetes with a BMI greater than or equal to 40 kg/m2 (greater than or equal to 37.5 kg/m2 for Asian Americans), metabolic surgery is recommended if weight loss cannot be achieved or maintained with nonsurgical methods.
- For patients with type 2 diabetes with a BMI greater than or equal to 30 to 34.9 kg/m2 (greater than or equal to 27.5 to 32.4 kg/m2 for Asian Americans), metabolic surgery may be considered if weight loss cannot be achieved or maintained with nonsurgical methods.
- Metabolic surgery should be performed only in high-volume centers by an experienced multidisciplinary team.
- Post surgery, patients will require lifelong support and monitoring of their nutritional, metabolic, and micronutrient status.
- Assess the need for mental health services for ongoing medical and psychosocial changes post surgery.
- Medical devices for short-term weight loss approved by the FDA (Food and Drug Administration) include implanted gastric balloons, gastric aspiration devices, and a vagus nerve stimulator.
Pharmacologic Approaches to Glycemic Treatment
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- Treatment for most individuals with type 1 diabetes involves early initiation of CGM and continuous subcutaneous insulin infusion or multiple daily injections of prandial and basal insulin.
- Treatment should be based on efficacy, effects on renal and cardiovascular comorbidities, access and cost, impact on weight, patient preference, and hypoglycemia risk.
- Insulin analogs (or inhaled insulin) are preferred over injectable human insulin to decrease the risk of hypoglycemia.
- For type 2 diabetes, metFORMIN is the preferred initial medication and should be continued for as long as it is tolerated. Lifestyle changes should also be included with the therapy.
- Consider introducing insulin to patients with type 2 diabetes if one of the following is present:
- Continued weight loss (catabolism)
- Symptomatic hyperglycemia
- A1c greater than 10%
- Blood glucose greater than or equal to 300 mg/dL
- For patients with newly diagnosed type 2 diabetes who have an A1c greater than or equal to 1.5% above their glycemic target, consider dual therapy.
- Consider sodium-glucose cotransporter 2 (SGLT2) inhibitors or glucagon-like peptide 1 (GLP-1) receptor agonists for patients with type 2 diabetes with known CVD or with known chronic kidney disease (CKD).
- A SGLT2 inhibitor is preferred for patients with type 2 diabetes and CVD who are also at a high risk for heart failure.
- A GLP-1 is preferred over insulin for its glucose-lowering effect in type 2 diabetes.
- Reevaluate the medication regimen at routine intervals (every 3 to 6 months) for optimal management.
- For all individuals taking insulin, or for those at high risk for hypoglycemia, glucagon should be prescribed. Education regarding the use and administration of glucagon should be provided to caregivers, school personnel, and any others providing support to an individual with diabetes.
Cardiovascular Disease and Risk Management
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- Measure blood pressure (BP) at all visits. Patients with a BP greater than or equal to 130/80 mmHg should follow up with a BP reading confirmation on a different day using multiple readings.
- All patients with hypertension (HTN) should be encouraged to monitor their BP at home.
- For patients with diabetes and HTN, considerations should include the following:
- An individualized treatment plan based on patient preferences and risk stratification.
- Target BP of less than 130/80.
- For patients with diabetes and preexisting HTN who are also pregnant, and who are being treated with antihypertensive therapy, BP targets should be between 110/85 and 135/85 mmHg.
- Patients with diabetes and a BP greater than 120/80 mmHg should be treated with the following lifestyle modifications:
- Weight loss, if appropriate
- DASH (Dietary Approaches to Stop Hypertension) diet
- Increased potassium intake
- Moderation of alcohol intake
- Increased physical activity
- For patients with a confirmed BP greater than or equal to 130/80 mmHg, lifestyle modifications and pharmacologic therapy are recommended.
- For patients with a confirmed BP greater than or equal to 160/100 mmHg, lifestyle modifications and two different antihypertensives are recommended.
- Treatment of HTN in the setting of diabetes should also address the risk of CVD. Treatment may include angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), thiazide-like diuretics, and/or dihydropyridine calcium channel blockers.
- Multidrug regimens may be required for HTN management, but caution should be used with certain combinations.
- An ACE inhibitor or an ARB is the recommended first-line treatment for patients with diabetes and HTN.
- Resistant hypertension with type 2 diabetes (greater than or equal to 140/90 mmHg despite other treatments) may also require mineralocorticoid receptor antagonist therapy.
- Serum creatinine, estimated glomerular filtration rate (eGFR), and serum potassium should be monitored within 7 to 14 days of initiation of therapy and at least once annually for patients being treated with an ACE inhibitor, ARB, or diuretic.
- For lipid management, lifestyle modifications should focus on weight loss and the inclusion of a Mediterranean or DASH diet. Encourage a reduction of saturated fat intake and an increase of viscous fiber, increased activity, and an intake of plant stanols or sterols.
- Monitor lipid levels in adults (less than 40 years old) not taking statins or other lipid-lowering therapy at initial diagnosis and at least every 5 years, or more frequently if indicated.
- Monitor lipid levels 4 to 12 weeks after the initiation of statin or lipid-lowering therapy.
- For patients 40 to 75 years old with diabetes but without CVD, moderate statin therapy is indicated along with lifestyle therapy.
- For patients 40 to 70 years old with diabetes and at high risk for CVD, high-intensity statin therapy is recommended.
- For secondary prevention in patients with diabetes and CVD, aspirin therapy (75 to 162 mg/day) is recommended.
- Dual antiplatelet therapy should be initiated for patients with diabetes according to the risk or presence of CVD.
- Use caution with thiazolidinediones in patients with type 2 diabetes due to the increased risk of heart failure.
- For patients with type 2 diabetes and heart failure, a sodium-glucose cotransporter 2 inhibitor (SGLT2) is recommended.
- Consider screening adults with diabetes for asymptomatic heart failure by measuring B-type natriuretic peptide (BNP) or N-terminal pro-BNP (NT-proBNP).
- To guide CVD prevention and limb preservation, screening for peripheral arterial disease (PAD) is recommended for asymptomatic adults with diabetes who are 50 years of age or older.
Chronic Kidney Disease (CKD) and Risk Management
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- Optimize glucose control and BP to reduce the risk or slow the progression of CKD.
- At least annually, urine albumin and estimated glomerular filtration rate should be assessed in patients who have had type I diabetes for a duration of 5 years or more, and in all patients with type II diabetes.
- Patients with established diabetic kidney disease should have their urine albumin and estimated glomerular filtration rate assessed 1 to 4 times a year.
- A sodium-glucose cotransporter 2 inhibitor should be prescribed in the following situations:
- For diabetic kidney disease, when urine albumin is greater than or equal to 200 mg/g and eGFR rate is greater than or equal to 20 mL/minute/1.73m2.
- To reduce disease progression and for cardiovascular risk reduction in CKD, when urinary albumin is normal to 200 mg/g and eGFR is less than or equal to 20 mL/minute/1.73m2.
- A nonsteroidal mineralocorticoid receptor agonist, such as finerenone, is recommended for patients who are unable to use a sodium-glucose cotransporter 2 inhibitor.
- A 30% or greater reduction in urinary albumin is recommended to slow CKD progression.
- Renin-angiotensin system blockade should not be discontinued for minor creatinine increases without volume depletion.
- For patients with stage 3 or higher kidney disease, protein intake should be a maximum of 0.8 g/kg body weight. Higher protein intake should be considered for patients on dialysis.
- For nonpregnant patients with diabetes and hypertension
- An ACE inhibitor or ARB is recommended for elevated urine albumin of 30 to 299 mg/g.
- An ACE inhibitor or ARB is strongly recommended for elevated urine albumin greater than or equal to 300 mg/g, with or without an eGFR of less than 60 mL/minute/1.73 m2.
- Monitor serum creatinine and serum potassium in patients taking ACE inhibitors or ARBs.
- ACE inhibitors and ARBs are not recommended for patients with diabetes who have normal BP and kidney function.
- A nephrology referral should be given in the following situations:
- When a patient has an eGFR of less than 30 mL/minute/1.73 m2 and/or a continuously increasing urine albumin level.
- When there is uncertainty about the etiology or management of the kidney disease.
- For rapidly progressing kidney disease.
Retinopathy, Neuropathy, and Foot Care
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- Perform eye exams at routine intervals.
- Type 1 diabetes: within 5 years of onset
- Type 2 diabetes: at time of diagnosis, every 1 to 2 years if no retinopathy is noted, and a minimum of once a year once retinopathy is identified.
- Optimize glycemic control, BP, and serum lipids to reduce the risk or slow the progression of diabetic retinopathy.
- All patients with diabetes should be screened for peripheral neuropathy at routine intervals and as needed.
- Patients with known sensory loss or prior ulcerations and/or amputation(s) should have their feet inspected at every visit. All other patients should be examined annually.
- Pharmacologic treatment for diabetic neuropathic pain includes gabapentinoids, serotonin-norepinephrine reuptake inhibitors, sodium channel blockers, and tricyclic antidepressants.
- Signs and symptoms of diabetic autonomic neuropathies should be discussed during a history and physical exam. Diabetic autonomic neuropathies may include the following:
- Resting tachycardia and/or orthostatic hypotension
- Hypoglycemia unawareness
- Gastroparesis
- Constipation, fecal incontinence, or diarrhea
- Erectile dysfunction
- Neurogenic bladder
- Sudomotor dysfunction with an increase or decrease in sweating
Older Adults
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- Assess cognitive, psychological, and medical function, and ability for self-care as well as functional independence at initial visit, annually, and as needed.
- Hypoglycemia should be avoided and should be managed by adjusting glycemic targets and pharmacologic interventions.
- Simplify treatment plans, as appropriate, to decrease the risk of hypoglycemia and polypharmacy.
- Consider the inclusion of agents that reduce cardiorenal risk for older adults with type 2 diabetes and have or are at risk of atherosclerotic CVD, heart failure, and/or CKD.
- Adults with type 1 diabetes should have CGM to reduce the risk of hypoglycemia.
- Diabetes education should be considered for the staff of skilled nursing facilities and long-term care centers to improve the management and care of patients with diabetes.
- Protein intake and other nutritional benefits should be monitored, along with resistance training and/or weight-bearing exercise and other regular exercise for those who can engage safely in such activities.
- Patients with type 2 diabetes who are obese/overweight should be assessed for weight loss (i.e., 5% to 7%) to improve mobility, quality of life, and physical function. Older adults with diabetes are commonly overtreated with medication, and this should be avoided.
- All therapies may be relaxed for end-of-life care. Care should focus on comfort, palliation, and the preservation of dignity and quality of life.
Children and Adolescents
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- Education and interventions should be age-appropriate and include individual nutrition therapy, encouragement of physical activity, and strategies to prevent hypoglycemia.
- Carbohydrate intake should be monitored to achieve optimal glycemic control.
- At the initial visit and at all follow-up visits, assess psychosocial status and evaluate stress regarding family and peers; also assess for disturbed eating behaviors.
- Consider screening for thyroid disease, celiac disease, and other autoimmune disorders at the initial visit and as needed.
- Measure BP at every visit, and measure lipid levels soon after diabetes diagnosis and at routine intervals. If abnormal, medical nutrition therapy is recommended.
- Encourage cessation of all tobacco products, e-cigarettes, and alcohol. Screening should be done at initial diagnosis and routinely.
- Children and adolescents should be screened for microvascular complications at each visit, and they should be screened for nonalcoholic fatty liver disease, obstructive sleep apnea, polycystic ovary syndrome (in adolescent girls), CVD, and dyslipidemia annually.
- Screen for prediabetes and type 2 diabetes in appropriate children and adolescents.
- Psychosocial care and behavioral health professionals should be included on the treatment team and in the care plan.
Management of Diabetes in Pregnancy
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- Beginning at puberty, females with diabetes should be counseled regarding potential reproduction and preconception during routine diabetes visits and care. Family planning should be included along with contraception consideration.
- Maintain A1c less than 6.5% (48 mmol/mol) prior to conception to reduce the risk of preeclampsia, congenital anomalies, macrosomia, and additional complications.
- Lifestyle modifications may be sufficient to manage GDM.
- Insulin is the preferred treatment for hyperglycemia in GDM. Insulin does not cross the placenta.
- MetFORMIN should be discontinued once a pregnancy is confirmed, or if being used to treat polycystic ovary syndrome, should be discontinued by the end of the first trimester.
- Low-dose aspirin (100 mg to 150 mg), started at 12 to 16 weeks gestation, is recommended to lower the risk of preeclampsia for pregnant individuals with type 1 or type 2 diabetes.
Diabetes Care in the Hospital
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- For all patients with diabetes or for those with hyperglycemia (blood glucose greater than 140 mg/dL) admitted to the hospital, perform an A1c if one has not performed in the last 3 months.
- Validated or computerized protocols should guide insulin administration.
- Consultation with a diabetes educator or team should be considered for all patients with diabetes who are admitted to the hospital.
- For patients with persistent hyperglycemia at a threshold greater than or equal to 180 mg/dl (10 mmol/L), checked two separate times, insulin therapy should be started. Once therapy is started, a glucose target range of 140 to 180 mg/dl (7.8 to 10 mmol/L) is recommended for noncritical and critical patients.
- The preferred treatment for hospitalized noncritically ill patients with poor oral intake or for those taking nothing by mouth (NPO) is basal insulin or basal insulin with bolus correction. For those with adequate oral intake, basal, prandial, and correction insulin is preferred.
- Sole use of sliding-scale insulin is not recommended in the hospital setting.
- The adoption and implementation of a hypoglycemia management protocol is recommended.
- For individuals using personal CGM devices, consider allowing CGM use in the hospital setting, as clinically appropriate, with confirmatory POC blood glucose measurements to guide insulin dosing.
- While use of a personal continuous glucose monitor is not FDA approved for inpatient use, such use may be supported during hospitalization when self-management is feasible and supervision is available.
- Diabetes ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS)
- Treat and correct any underlying causes.
- The standard of care is continuous intravenous insulin.
- Administer a transition dose of subcutaneous basal insulin at least 2 to 4 hours before discontinuation of the IV insulin infusion.
- Discharge
- Coordinate the following
- Perform a medication reconciliation and review any new medications or prescriptions.
- Review with the patient which practitioner will provide the follow-up visit and assess the patient's level of understanding regarding the following: diabetes diagnosis, blood glucose self-monitoring, blood glucose home goals, when to call the practitioner, medications and directions for administering the medications, proper use of needles, and syringes and their disposal.
- Patients should be provided with medication, supplies (i.e., test strips for blood glucose), medical equipment, and any related education at the time of their discharge.
- Schedule a follow-up appointment with a primary care provider, an endocrinologist, or a diabetes educator.
- Provide referrals for ongoing outpatient education and follow-up.
Reference
American Diabetes Association (2024). Standards of care in diabetes—2024.
Diabetes Care, 47(Suppl. 1), S1–S313. Retrieved June 2024 from
https://diabetesjournals.org/care/issue/47/Supplement_1
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